Chair of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
Respiratory Pharmacology Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
Drugs. 2015 Sep;75(14):1575-85. doi: 10.1007/s40265-015-0450-6.
Chronic obstructive pulmonary disease (COPD) guidelines and strategies suggest escalating treatment, mainly depending on the severity of airflow obstruction. However, some de-escalation of therapy in COPD would be appropriate, although we still do not know when we should switch, step-up or step-down treatments in our patients. Unfortunately, trials comparing different strategies of step-up and step-down treatment (e.g. treatment initiation with one single agent and then further step-up if symptoms are not controlled versus initial use of double or triple therapy, possibly with lower doses of the individual components, or the role of N-acetylcysteine in combination therapy for a step-down approach) are still lacking. In general, there is a large and often inappropriate use of the inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) combination. However, the withdrawal of the ICS in COPD patients at low risk of exacerbation can be safe, provided that patients are under regular treatment with long-acting bronchodilators. Maximising the treatment in patients with a degree of clinical instability by including an ICS in the therapeutic regimen is useful to control the disease, but may not be needed during periods of clinical stability. In patients with severe but stable COPD, the withdrawal of the ICS from triple therapy [LABA + long-acting muscarinic antagonist (LAMA) + ICS] is possible, but not when the patient has been hospitalised for an acute exacerbation of COPD. We must still establish how long we should wait before withdrawing the ICS. It is still unclear whether the same is true when only the LABA or the LAMA is withdrawn while continuing treatment with the other bronchodilator and the ICS. In any case, we strongly believe that it is always better to avoid a therapeutic step-up progression when it is not needed rather than being forced subsequently into a step-down approach in which the outcome is always unpredictable.
慢性阻塞性肺疾病（COPD）指南和策略建议逐步升级治疗，主要取决于气流阻塞的严重程度。然而，COPD 的治疗降级也是合适的，尽管我们仍然不知道何时应该在患者中转换、升级或降级治疗。不幸的是，比较不同升级和降级治疗策略的试验（例如，使用单一药物起始治疗，如果症状未得到控制则进一步升级，而不是初始使用双或三联治疗，可能使用较低剂量的单个成分，或 N-乙酰半胱氨酸在降级治疗中的作用）仍然缺乏。一般来说，吸入性皮质类固醇（ICS）/长效β2-激动剂（LABA）联合治疗的应用范围广泛且往往不适当。然而，在低加重风险的 COPD 患者中，只要患者正在接受长效支气管扩张剂的常规治疗，停止 ICS 治疗可能是安全的。在具有一定临床不稳定程度的患者中，通过在治疗方案中加入 ICS 来最大限度地提高治疗效果，有助于控制疾病，但在临床稳定期间可能不需要。在严重但稳定的 COPD 患者中，从三联疗法（LABA+长效毒蕈碱拮抗剂（LAMA）+ICS）中撤出 ICS 是可能的，但当患者因 COPD 急性加重而住院时则不行。我们仍需确定在撤出 ICS 之前需要等待多长时间。当仅撤出 LABA 或 LAMA 而继续使用其他支气管扩张剂和 ICS 时，情况是否相同仍不清楚。在任何情况下，我们都强烈认为，当不需要治疗升级时，最好始终避免升级，而不是被迫随后采用降级治疗，降级治疗的结果总是不可预测的。
